Preprocedural CALLY Index as a Novel Predictor of Pacemaker Requirement After Transcatheter Aortic Valve Replacement

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Severe symptomatic aortic stenosis treated with transcatheter aortic valve replacement (TAVR) (n=812). Intervention: Preprocedural C-reactive protein-albumin-lymphocyte (CALLY) index (Quartile 4: >0.82) vs. Preprocedural CALLY index Quartile 1 (0.02 ≤ CALLY ≤ 0.36). Primary outcome: New permanent pacemaker implantation (PPI) within 30 days after TAVR (HR 0.57, 95% CI 0.35-0.94, p=0.026).

Q: What does this research mean for the field?

A higher preprocedural C-reactive protein-albumin-lymphocyte (CALLY) index is independently associated with a significantly reduced risk of 30-day permanent pacemaker implantation following transcatheter aortic valve replacement. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Haitham Abu Khadija; Nizar Abu Hamdeh; Mohammad Masu'd; Duha Najajra; Ali Abdullah; Jebrin Alkrinawi; Alena Kirzhner; Zeina Sinnokrot; Lilian Jofa; Firas Besharieh; Rashed Saed; Alaa Zayed; Sarah Awad; Tal Schiller; Mohammad Alnees

doi:10.1016/j.cjco.2026.03.008

April 1, 2026CJC OpenOpen Access

Preprocedural CALLY Index as a Novel Predictor of Pacemaker Requirement After Transcatheter Aortic Valve Replacement

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Key result

Higher preprocedural CALLY index is linked to ~43% lower 30-day pacemaker requirement after TAVR.

HR 0.57
95% CI 0.35-0.94
P=0.026
n=812

Figures

Why the study?

Permanent pacemaker implantation is a common complication after TAVR, but while procedural and electro-anatomic factors are established, patient-related susceptibility markers remain unclear.

Does a higher preprocedural C-reactive protein-albumin-lymphocyte (CALLY) index predict a reduced risk of new permanent pacemaker implantation within 30 days in adults with severe symptomatic aortic stenosis undergoing TAVR?

Key Points

To evaluate whether the preprocedural C-reactive protein-albumin-lymphocyte (CALLY) index independently predicts and stratifies the risk of new permanent pacemaker implantation within 30 days after transcatheter aortic valve replacement.
Retrospectively analyzed 812 consecutive patients undergoing transcatheter aortic valve replacement with complete baseline laboratory tests between 2010 and 2025.
Calculated baseline CALLY index scores from albumin, lymphocyte count, and C-reactive protein, stratifying patients into quartiles (Q1 to Q4).
Evaluated the primary endpoint of new permanent pacemaker implantation within 30 days using Kaplan-Meier analysis and multivariable Cox proportional hazards regression models.
Within 30 days after transcatheter aortic valve replacement, 145 patients (17.9%) required permanent pacemaker implantation at a median time of 4 days (IQR 2-9).
Compared with Q1, higher CALLY index quartiles showed progressively lower unadjusted risk of pacemaker implantation: Q2 HR 0.64 (95% CI 0.42-0.99), Q3 HR 0.63 (95% CI 0.41-0.98), and Q4 HR 0.50 (95% CI 0.31-0.79).
After multivariable adjustment for clinical, anatomic, and procedural factors, the highest quartile remained independently protective against pacemaker implantation compared with Q1 (HR 0.57, 95% CI 0.35-0.94, P = 0.026).

Study Design

Type

Cohort (n=812)

Multicenter

No

Structured PICO

Does a higher preprocedural C-reactive protein-albumin-lymphocyte (CALLY) index predict a reduced risk of new permanent pacemaker implantation within 30 days in adults with severe symptomatic aortic stenosis undergoing TAVR?

P

Population

812 consecutive adults (53.2% female) with severe symptomatic aortic stenosis undergoing transfemoral TAVR without preexisting pacemakers, followed for 30 days.

E

Exposure

Risk stratification by preprocedural C-reactive protein-albumin-lymphocyte (CALLY) index, calculated from routine blood tests within 3 days before TAVR as (Serum albumin [g/L] × Lymphocyte count [10^9/L] ÷ CRP [mg/L]) × 10, stratified into quartiles: Q2 (0.36 < CALLY ≤ 0.49; mean = 0.41), Q3 (0.49 < CALLY ≤ 0.82; mean = 0.63), and Q4 (CALLY > 0.82; mean = 2.30). All patients underwent transfemoral TAVR with single antiplatelet therapy (aspirin 100 mg daily or clopidogrel 75 mg daily initiated 1 day prior unless on chronic antiplatelet/anticoagulation) and unfractionated heparin (ACT >250 seconds).

C

Comparator

Lowest baseline CALLY index quartile (Q1: 0.02 ≤ CALLY ≤ 0.36; mean = 0.24) as the referent group; predictive discrimination was also compared against the preprocedural neutrophil-to-lymphocyte ratio (NLR).

O

Outcome

New permanent pacemaker implantation (PPI) within 30 days after TAVR (defined as first implantation of a permanent device following the index procedure occurring during hospitalization or within 30 days, analyzed as a time-to-event outcome).hard clinical

Main Result

Hazard Ratio: 0.57 (95% CI 0.35–0.94)

p-value: p=0.026

Limitations

Retrospective, single-centre analysis susceptible to selection and information bias
Residual confounding cannot be completely excluded despite multivariable and sensitivity adjustments
Limited event counts in several subgroup strata (e.g., nonhypertensive and balloon-expandable valve subgroups)
Detailed computed tomography-derived anatomic metrics (such as membranous septum length and cusp-specific calcium phenotype) were not consistently available
CALLY index was measured at a single preprocedural time point without longitudinal assessment
Long 15-year recruitment period (2010-2025) over which TAVR technology and procedural strategies evolved
Retrospective, single-center observational cohort design without a formal a priori sample size calculation
Long recruitment period (2010-2025) spanning temporal changes in TAVR techniques, device iterations, and pacemaker indications
Subgroup, secondary, and discrimination analyses were exploratory and hypothesis-generating, not intended to establish a standalone prediction model

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Implication

Higher CALLY index was associated with lower post-TAVR pacemaker risk; hypothesis-generating for risk stratification pending prospective validation.

Abstract

Background: Permanent pacemaker implantation (PPI) is a common complication after transcatheter aortic valve replacement (TAVR).While procedural and electro-anatomic factors are well established, patient-related susceptibility markers remain unclear.We aimed to evaluate whether the preprocedural C-reactive protein-albumin-lymphocyte (CALLY) index independently predicts and aids in risk stratification for 30-day PPI after TAVR. Methods:We retrospectively analyzed 812 consecutive TAVR patients with complete baseline labs (2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018)(2019)(2020)(2021)(2022)(2023)(2024)(2025).The CALLY index was calculated as (albumin lymphocytes CRP) 10, and patients were stratified into quartiles (Q1-Q4).The primary endpoint was new PPI within 30 days.Kaplan-Meier curves and Cox regression assessed the association between CALLY quartiles and PPI risk.Multivariable models adjusted for prespecified clinical, anatomic, and procedural factors.Subgroup analyses evaluated consistency across age, sex, hypertension, and valve type.Results: Median time to PPI was 4 days (IQR 2-9), and 145 patients (17.9%) required implantation.Higher CALLY quartiles were associated with a progressively lower PPI risk compared with Q1: Q2 HR 0.64 (95% CI 0.42-0.99),Q3 HR 0.63 (95% CI 0.41-0.98),and Q4 HR 0.50 (95% CI 0.31-0.79).After multivariable adjustment, Q4 remained independently protective (HR 0.57, 95% CI 0.35-0.94).The protective effect of Q4 was consistent across subgroups, including age 80 years, males, females, hypertensive patients, and recipients of self-expanding valves.No significant effect modification was observed.Conclusions: A higher preprocedural CALLY index was independently linked to a lower 30day pacemaker requirement after TAVR.As a simple, inexpensive marker, CALLY may improve pre-TAVR risk stratification and guide peri-procedural planning.

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Cite This Study

Khadija et al. (2026) conducted a cohort in Severe symptomatic aortic stenosis treated with transcatheter aortic valve replacement (TAVR) (n=812). Preprocedural C-reactive protein-albumin-lymphocyte (CALLY) index (Quartile 4: >0.82) vs. Preprocedural CALLY index Quartile 1 (0.02 ≤ CALLY ≤ 0.36) was evaluated on New permanent pacemaker implantation (PPI) within 30 days after TAVR (HR 0.57, 95% CI 0.35-0.94, p=0.026). A higher preprocedural CALLY index (Quartile 4 vs Quartile 1) was independently associated with a lower 30-day pacemaker requirement after TAVR (adjusted HR 0.57, 95% CI 0.35-0.94, P=0.026).

synapsesocial.com/papers/69d34cee9c07852e0af97319 https://doi.org/10.1016/j.cjco.2026.03.008

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Preprocedural CALLY Index as a Novel Predictor of Pacemaker Requirement After Transcatheter Aortic Valve Replacement

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Preprocedural CALLY Index as a Novel Predictor of Pacemaker Requirement After Transcatheter Aortic Valve Replacement

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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